product order form
PRODUCT ORDER FORM
Rehab
Billing Address:
Thank you for your order!
Name ___________________________________________ Profession _____________________________ Company Name_ ________________________________________________________________________
Please fax your order (and tax-exempt certificate, if applicable) to:
Company Address_ ______________________________________________________________________
1-800-554-9775
Company Address 2______________________________________________________________________
Or mail your order (and tax-exempt certificate, if applicable) to:
City_________________________________________County_____________________________________ State _ ___________________________________________ Zip___________________________________ Phone_____________________________________________________
PESI, Inc. Attn: Order Entry PO BOX 1000 Eau Claire, WI 54702
E-mail address__________________________________________________________________________ Please note: Confirmation/receipts are sent only via e-mail.
For office use only:
Shipping Address (if different from above):
Check #: _______________________
Company Address_ ______________________________________________________________________
Order #: _______________________
Company Address 2______________________________________________________________________ City_________________________________________County_____________________________________ State _ ___________________________________________ Zip___________________________________
Product Order: Qty
Item Number
_
Title
Payment Information: Check ■
Master Card ■
Price
Mail Code: ____________
Visa ■
Am Express ■
Discover ■
Card Number_____________________________________________________________________ Exp Date__________________________________________ V Code_ _______________________
Total
Product total $ _________________ *Shipping
_________________
Subtotal
_________________
**Tax
_________________
Total $
_________________
Name on Card ___________________________________________ Signature_______________________________________________ Tax-Exempt ID# (if applicable): _ ___________________________
*Domestic shipping is $6.95 first item + $2.00 each add’l item. **AL, AZ, AR, CA, CO, CT, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, NE, NV, NJ, NM, NY, NC, ND, OH, OK, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA WASHINGTON DC, WV, WI, WY residents add applicable state and local taxes.
If you are a tax-exempt organization, please provide us with your tax-exempt ID # and attach a copy of your tax-exempt certificate with this order. *If you have any questions, are ordering more than 4 items, or are outside the U.S., please call our Customer Service department at 1-800-844-8260
Rehab
Billing Address:
Thank you for your order!
Name ___________________________________________ Profession _____________________________ Company Name_ ________________________________________________________________________
Please fax your order (and tax-exempt certificate, if applicable) to:
Company Address_ ______________________________________________________________________
1-800-554-9775
Company Address 2______________________________________________________________________
Or mail your order (and tax-exempt certificate, if applicable) to:
City_________________________________________County_____________________________________ State _ ___________________________________________ Zip___________________________________ Phone_____________________________________________________
PESI, Inc. Attn: Order Entry PO BOX 1000 Eau Claire, WI 54702
E-mail address__________________________________________________________________________ Please note: Confirmation/receipts are sent only via e-mail.
For office use only:
Shipping Address (if different from above):
Check #: _______________________
Company Address_ ______________________________________________________________________
Order #: _______________________
Company Address 2______________________________________________________________________ City_________________________________________County_____________________________________ State _ ___________________________________________ Zip___________________________________
Product Order: Qty
Item Number
_
Title
Payment Information: Check ■
Master Card ■
Price
Mail Code: ____________
Visa ■
Am Express ■
Discover ■
Card Number_____________________________________________________________________ Exp Date__________________________________________ V Code_ _______________________
Total
Product total $ _________________ *Shipping
_________________
Subtotal
_________________
**Tax
_________________
Total $
_________________
Name on Card ___________________________________________ Signature_______________________________________________ Tax-Exempt ID# (if applicable): _ ___________________________
*Domestic shipping is $6.95 first item + $2.00 each add’l item. **AL, AZ, AR, CA, CO, CT, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, NE, NV, NJ, NM, NY, NC, ND, OH, OK, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA WASHINGTON DC, WV, WI, WY residents add applicable state and local taxes.
If you are a tax-exempt organization, please provide us with your tax-exempt ID # and attach a copy of your tax-exempt certificate with this order. *If you have any questions, are ordering more than 4 items, or are outside the U.S., please call our Customer Service department at 1-800-844-8260
